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Registration
AIJAZ FATIMA ANTENATAL REGISTRY
Booking Visit
MR #
Date
Site
Clifton
Kemari
Nazimabad
North Nazimabad
Sukkur
Name
Husband's Name
Age
Contact Number
Address
Ethnicity
Sindhi
Punjabi
Baloch
Urdu
Pushto
Saraiki
Others
Education
Less than primary
Primary
Secondary
Graduation
Post-Graduation
Occupation of Wife
Occupation of Husband
Gravida
1
2
3
4
5
> than 5
Parity
Miscarriage
1
2
3
4
5
Termination of Pregnancy
1
2
3
4
5
Ectopic
1
2
3
Gestational Trophoblastic Disease
1
2
3
>3
LMP
EDD
USSEDD
Gestation at Booking
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
Mode of Conception
Spontaneous
Ovulation Induction
IUI
IVF/ICSI
General Physical Examination at Booking
Height (cm)
Weight (Kg)
BMI
Systolic BP (mmHg)
Diastolic BP (mmHg)
Mean Arterial Pressure
Pulse
Mid-arm Circumference
Pallor
Yes
No
Edema
No
Pedal (+)
Pedal (++)
Pedal (+++)
Sacral (+)
Sacral (++)
Sacral (+++)
Breasts
Varicose Veins
Risk Factors & Associated diseases at Booking
Risk Factors at Booking
Nulliparity
Grand multiparity
Pregnancy interval > 10 years
Pregnancy interval < 1 year
PIH/Pre-eclampsia in previous pregnancy
Gestational diabetes in previous pregnancy
History of intrahepatic cholestasis in previous pregnancy
Family history of preeclampsia
Family history of Diabetes
Previous baby weighing > 4 Kgs
Multifetal pregnancy
Age > 40 years
BMI > 35 Kg/m2
Recurrent Miscarriages
History of Blood transfusion/IV iron
Addiction:
Smoking/Vapes
Pan/Chaliya/Gutka
Passive Smoking
Recreational drugs
Alcohol
Others (specify):
Associated diseases at booking
Type I or II D/M
Chronic HTN
Thyroid disease
PCOs
Epilepsy
Chronic kidney disease
Cardiovascular disease
Autoimmune disease/SLE/APLA
Respiratory disease
Anemia
Thalassemia
Psychosocial Disease
Allergies
Others (specify):
Previous surgical history
Last pap smear/HPV
Within last 3-5 years
> 5 years
Not done
Investigations at Booking
Hb (gm/dl)
HCT (%)
PLTS (x10E9/L)
HBsAg
Reactive
Non reactive
ANTI HCV
Reactive
Non Reactive
RBS
FBS
HBA1C
OGTT - FBS
OGTT - 1 hour
OGTT - 2 hour
Blood group
A+
A-
B+
B-
O+
O-
AB+
AB-
Red cell antibody screening
Negative
Positive
Not done
Urine Dr
Ultrasound at booking
Yes
No
Supplements
Folic acid
Multivitamin
Others
Past Obstetric History
Past Obstetric History
Birth Date
Gestation
Duration of labor
IOL
Yes
No
Mode of delivery
NVD
Instrumental vaginal delivery
Vaginal breech delivery
VBAC
Ceasarean
Status
Live
Stillbirth
TOP
Gender
Male
Female
Birth weight
<2.5 Kg
2.5-3.9 Kg
>4.0 Kg
Complications
Antenatal complications
Intrapartum complications
Postpartum
Neonatal
Breast-feeding
Not at all
Till 6 weeks
Till 3-6 months
Till 1 year
Till 2 year
Contraception
Coitus interruptus
Condom
IUCD
Implant
COCPs
Others
None
Specify Others
